Enhanced radioresponse with a novel recombinant human endostatin protein via tumor vasculature remodeling: Experimental and clinical evidence

doi:10.1016/j.radonc.2012.10.022

Radiotherapy and Oncology

Volume 106, Issue 1, January 2013, Pages 130-137

https://doi.org/10.1016/j.radonc.2012.10.022 Get rights and content

Abstract

Purpose

This study aimed to examine the effect of the novel recombinant human endostatin (rh-Endo) protein on tumor vasculature, and to explore and evaluate the optimal scheduling of rh-Endo and radiotherapy (RT).

Methods

Tumor-perfusion parameters and hypoxia were monitored after rh-Endo treatment in 10 non-small cell lung-cancer (NSCLC) patients. Eight-week female C57BL/6J mice were randomized to receive rh-Endo or control (saline) once daily for 12 days when Lewis lung carcinoma (LLC) reached approximately 100–150 mm³. On planned days, tumors were measured for cell apoptosis, microvessel density, pericytes, blood-vessel morphology, and tumor hypoxia. The tumor response under different combinations of rh-Endo and RT schedules was evaluated.

Results

Tumor hypoxia was significantly reduced 5 days after rh-Endo in NSCLC patients, and a similar result was found in the LLC mouse model. The anti-tumor effect was markedly enhanced when RT was administered within the remodeling period compared to any other treatment schedule. rh-Endo treatment remodeled the tumor vasculature after 5 days by reducing microvessel density and increasing pericytic coverage of the vessel endothelium.

Conclusion

This study demonstrated decreased hypoxia in animals and patients upon rh-Endo treatment, which also enhanced the radioresponse within the vasculature-remodeling period. The optimal clinical combination of rh-Endo and RT warrants further investigation.

Section snippets

Treatment schedule, tumor vasculature evaluation, and tumor-hypoxia evaluation of eligible patients

To explore the effect of rh-Endo on the tumor vasculature of human tumors, lung cancer patients were recruited from the Department of Oncology at Lianyungang First People’s Hospital in Lianyungang, China. All patients were screened and enrolled in the current study by oncologists according to the following criteria: (i) 18–65 years of age; (ii) diagnosed with NSCLC based on histopathological examination; (iii) lack of prior treatment; (iv) unresectable tumor with a maximum transverse diameter of

Tumor hypoxia improvement in NSCLC patients and LLC-bearing mice by rh-Endo

Tumor vascular and hypoxia modulation by rh-Endo were determined in ten eligible NSCLC patients. Changes in tumor size and tumor perfusion parameters (BF, BV, MTT, and PS) were measured (Supplementary files 3A,B). A significant increase in the BF of tumors on day 5 after rh-Endo compared with baseline and day 10 was observed (both p < 0.0001, Fig. 1A). PS was significantly reduced on days 5 and 10 compared with baseline after rh-Endo (both p < 0.001, Fig. 1B). However, no significant changes in BV

Discussion

The intrinsic mechanism underlying the contribution of angiogenesis inhibitors to the radioresponse is still unclear, despite a considerable amount of research in recent years. Some reviews have suggested that angiogenesis inhibitors and RT synergistically enhance the radioresponse of tumor growth in solid tumors [23], [24]. Importantly, further evidence has confirmed that different tumors treated with angiogenesis inhibitors can induce vascular normalization [25], [26], [27], [28].

Acknowledgements

This work were supported by the National Major Project of China (No. 2011ZX09302-001-01), the National Natural Science Foundation of China (No. 81172131), the National Basic Research Program of China (No. 2009CB941202), and the National Natural Science Foundation of China (No. 81201754). We are indebted to all colleagues at the Laboratory of Stem Cell Biology of Sichuan University who provided their assistance for this study. We particularly thank Drs. Zhou L, Wang YS, Wang LS, Fu XY, Wan XL,

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The prognosis of unresectable stage III non-small cell lung cancer (NSCLC) was poor even after concurrent chemoradiotherapy. There remains a great need to develop novel therapeutic agents in combination with CCRT to improve outcomes. This prospective study sought to evaluate the efficacy and toxicities of the addition of endostar, an anti-angiogenesis agent, to concurrent etoposide, cisplatin (EP) and radiotherapy for treatment of patients with NSCLC.
Patients with untreated pathologically confirmed inoperable stage III NSCLC were eligible. Radiation at doses of 60–66 Gy, four cycles of endostar (7.5 mg/m²/24 h × 120 h, 14 days/cycle), and two cycles of EP (etoposide 50 mg/m² on days 1–5 and cisplatin 50 mg/m² on days 1 and 8, 28 days/cycle) were delivered. The primary endpoint was progression-free survival (PFS). The secondary endpoints were response rate and overall survival (OS), locoregional relapse-free survival (LRFS) distant metastasis-free survival (DMFS) and adverse events (AE).
From November 2012 to June 2015, 73 patients were enrolled, and 67 patients were evaluable. The median age was 59 years. Sixty-six percent of the patients had squamous cell carcinoma. Grade ≥3 AEs occurred in 58.2% of the patients. The most common Grade ≥3 AE was leucopenia (44.8%). The response rate was 76.1%. The median times of PFS and OS were 13.3 months and 34.7 months, respectively. The 2-year PFS, OS, LRFS and DMFS rates were 34.8%, 59.9%, 54.7% and 68.5%, respectively.
For patients with unresectable stage III NSCLC, continuous intravenous endostar in combination with concurrent EP and radiotherapy did not prolong median PFS, although it got preferable OS, promising 2-year PFS with tolerable toxicities.
PDGFR-β inhibitor slows tumor growth but increases metastasis in combined radiotherapy and Endostar therapy
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Citation Excerpt :
In order to elucidate the effect of pericyte-targeted treatment in combined RT and Endostar therapy, 9 mice per group were treated as illustrated in Fig. 2A. As we previously found [4], the tumor volume in the RT + Endo group was mitigated in comparison to RT alone (P = .0080, Fig. 2B). Additionally, RT + Endo + CP673451 led to a marked retardation of tumor growth when compared to RT and RT + Endo groups (P = .0001, P = .0000), suggesting that inhibition of pericytes might play a role in the orthotopic tumor growth control in combined RT and Endostar therapy (Fig. 2B).
Pericytes are pivotal mural cells of blood vessels and play an essential role in coordinating the function of endothelial cells. Previous studies demonstrated that Endostar, a novel endostatin targeting endothelial cells, can enhance the effect of radiotherapy (RT). The present study addressed whether inhibiting pericytes could potentially improve the efficacy of combined RT and Endostar therapy.
Platelet-derived growth factor beta-receptor inhibitor (CP673451) was chosen to inhibit pericytes and RT (12 Gy) was delivered. Lewis lung carcinoma-bearing C57BL/6 mice were randomized into 3 groups: RT, RT + Endo, and RT + Endo + CP673451. Subsequently, tumor microvessel density (MVD), pericyte coverage, tumor hypoxia, and lung metastasis were monitored at different time points following different therapies.
Compared to the other two groups, RT + Endo + CP673451 treatment markedly inhibited tumor growth with no improvement in the overall survival. Further analyses clarified that in comparison to RT alone, RT + Endo significantly reduced the tumor MVD, with a greater decrease noted in the RT + Endo + CP673451 group. However, additional CP673451 accentuated tumor hypoxia and enhanced the pulmonary metastasis in the combined RT and Endostar treatment.
Tumor growth can be further suppressed by pericyte inhibitor; however, metastases are potentially enhanced. More in-depth studies are warranted to confirm the potential benefits and risks of anti-pericyte therapy.
Mesenchymal stem cells generate pericytes to promote tumor recurrence via vasculogenesis after stereotactic body radiation therapy
2016, Cancer Letters
Citation Excerpt :
Additionally, studies have shown that a number of inflammatory cytokines (including CXCR1, CXCR2, CCR2, TNF-α and MMP-2) stimulate MSC migration [31–34]; these cytokines are also up-regulated by RT [35,36]. Combined with our results on angiogenesis in this study (Fig. S1) and our previously published results [37,38], we postulate that the decreasing VEGF levels after SBRT may be due to repression of MVD. Taken together, these results suggest that vasculogenesis, and not angiogenesis, plays a key role in tumor recurrence after SBRT.
Stereotactic body radiation therapy (SBRT) is postulated to enhance the recruitment of mesenchymal stem cells (MSCs) into the tumor microenvironment, which promote tumor recurrence. The aim of this study is to determine the molecular mechanisms behind SBRT stimulating MSC migration and differentiation.
In vitro, mediated factors and migrated MSCs (post-SBRT) were generated. In vivo, bone-marrow derived MSCs were identified and harvested from green fluorescent protein (GFP)-expressing transgenic male mice and transplanted into sub-lethally irradiated recipient female mice to establish a model of bone marrow transplantation. Lewis lung carcinoma and malignant melanoma-bearing recipient mice were treated with SBRT, 14 Gy/1 fraction. The migration and differentiation potential of MSCs were characterized.
SBRT increased the release of stromal cell derived factor-1α (SDF-1α) and platelet-derived growth factor-B (PDGF-B) by tumor cells; these ligands bound to chemokine (C–X–C motif) receptor 4 (CXCR4) and platelet-derived growth factor receptor-β (PDGFR-β), respectively, on circulating bone marrow-derived MSCs, resulting in engraftment of the MSCs into the tumor parenchyma. The newly-homed MSCs differentiated into pericytes, which induced the tumor vasculogenesis, and promoted tumor regrowth. Targeted therapies, AMD3100 and imatinib abrogated MSC homing, vasculogenesis, and tumor regrowth.
Bone-marrow derived MSCs migrate to the tumor parenchyma and differentiate into pericytes, inducing tumor vasculogenesis after SBRT, and promoting tumor recurrence. MSC migration and maturation may be abrogated with AMD3100 and imatinib. This novel treatment strategy warrants clinical investigation.
Cutting-edge research in basic and translational radiation biology/oncology reflections from the 14th International Wolfsberg Meeting on Molecular Radiation Biology/Oncology 2015
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Gastrointestinal toxicities with combined antiangiogenic and stereotactic body radiation therapy
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Combining the latest targeted biologic agents with the most advanced radiation technologies has been an exciting development in the treatment of cancer patients. Stereotactic body radiation therapy (SBRT) is an ablative radiation approach that has become established for the treatment of a variety of malignancies, and it has been increasingly used in combination with biologic agents, including those targeting angiogenesis-specific pathways. Multiple reports have emerged describing unanticipated toxicities arising from the combination of SBRT and angiogenesis-targeting agents, particularly of late luminal gastrointestinal toxicities. In this review, we summarize the literature describing these toxicities, explore the biological mechanism of action of toxicity with the combined use of antiangiogenic therapies, and discuss areas of future research, so that this combination of treatment modalities can continue to be used in broader clinical contexts.
Phase II trial of recombinant human endostatin in combination with concurrent chemoradiotherapy in patients with stage III non-small-cell lung cancer
2015, Radiotherapy and Oncology
The objective of this study was to evaluate the efficacy and safety of Endostar combined with concurrent chemoradiotherapy (CCRT) in patients with stage III non-small-cell lung cancer (NSCLC).
Patients with unresectable stage III NSCLC were treated with Endostar (7.5 mg/m²/d) for 7 days at weeks 1, 3, 5, and 7, while two cycles of docetaxel (65 mg/m²) and cisplatin (65 mg/m²) were administered on days 8 and 36, with concurrent thoracic radiation to a dose of 60–66 Gy. Primary end points were short-term efficacy and treatment-related toxicity.
Fifty patients were enrolled into the study, and 48 were assessable. Of the 48 patients, 83% had stage IIIB and 65% had N3 disease. Median follow-up was 25.0 months. Overall response rate was 77%. The estimated median progression-free survival (PFS) was 9.9 months, and the estimated median overall survival (OS) was 24.0 months. The 1-, 2-, and 3-year local control rates were 75%, 67%, and 51%, PFS rates were 48%, 27%, and 16%, and OS rates were 81%, 50%, and 30%, respectively. All toxicities were tolerable with proper treatment.
The combination of Endostar with CCRT for locally advanced NSCLC patients was feasible and showed promising survival and local control rates.

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^☆: Note: This work was partly supported by the 11th Five Years Special Foundation for State Major Science and Technology of China (No. 2008ZX09312) and the National Natural Science Foundation of China (No. 30870734, No. 81172131, and No. 81201754). No benefits in any form have been or will be received from a commercial party directly or indirectly related to the subject of this article.

¹: These authors contributed equally to this work.

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Molecular radiobiologyEnhanced radioresponse with a novel recombinant human endostatin protein via tumor vasculature remodeling: Experimental and clinical evidence☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Treatment schedule, tumor vasculature evaluation, and tumor-hypoxia evaluation of eligible patients

Tumor hypoxia improvement in NSCLC patients and LLC-bearing mice by rh-Endo

Discussion

Acknowledgements

Int J Radiat Oncol Biol Phys

Radiother Oncol

Cancer Treat Rev

Cancer Cell

FEBS Lett

J Thoracic Oncol

Lung Cancer

Int J Radiat Oncol Biol Phys

Am J Pathol

Radiother Oncol

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Cancer Cell

Global cancer statistics

CA Cancer J Clin

Vascular permeability factor/vascular endothelial growth factor: a critical cytokine in tumor angiogenesis and a potential target for diagnosis and therapy

J Clin Oncol

Molecular radiobiology
Enhanced radioresponse with a novel recombinant human endostatin protein via tumor vasculature remodeling: Experimental and clinical evidence☆